Provider Demographics
NPI:1619523438
Name:MCENULTY, LISA MARIE (AAS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MCENULTY
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 KELLUM ST APT D305
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4396
Mailing Address - Country:US
Mailing Address - Phone:907-687-7966
Mailing Address - Fax:
Practice Address - Street 1:1027 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4306
Practice Address - Country:US
Practice Address - Phone:907-451-8164
Practice Address - Fax:907-451-0273
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist